Provider Demographics
NPI:1679787337
Name:DYNIA, JACLYN MARIE
Entity Type:Individual
Prefix:MISS
First Name:JACLYN
Middle Name:MARIE
Last Name:DYNIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 ASCHINGER BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2690
Mailing Address - Country:US
Mailing Address - Phone:440-476-8868
Mailing Address - Fax:
Practice Address - Street 1:1444 ASCHINGER BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-2690
Practice Address - Country:US
Practice Address - Phone:440-476-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2313213Medicare ID - Type Unspecified